Failure to Administer Medications According to Physician Orders
Penalty
Summary
A deficiency was identified when a resident was administered medications that were not in accordance with physician orders. The medication administration records (MAR) showed that the resident received as-needed (PRN) medications on multiple occasions when their documented assessment levels did not meet the parameters specified in the physician's orders. Despite the orders requiring certain criteria to be met before administration, the medications were given regardless of the resident's reported levels. Interviews with nursing staff revealed that medications were sometimes administered based on the resident's request, even when the required assessment levels were not present. One LPN admitted to giving the medication even though the resident did not meet the criteria and acknowledged that she should have contacted the physician instead. Facility policy requires medications to be administered according to prescriber orders, including any specified parameters, but this was not consistently followed in the case reviewed.
Plan Of Correction
Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6) 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 20 was not affected. Resident was interviewed and stated [R]. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Director of Nursing or designee in-serviced licensed nursing staff on documenting appropriate pain rating based on pain medication physician orders. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Director of Nursing or designee will audit 5 resident charts who received pain medications to determine that pain medications are administered appropriately in accordance with physician orders. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.